When I visit my pain management doctor, he hands me my monthly prescription for a small number of an opioid called Tramadol. He also offers an anecdote.
“I just met a dancer with New York City Ballet. Or maybe it was American Ballet Theatre, which one is at Lincoln Center?” he asks. His area is sports medicine, not the fine arts.
“They both are,” I reply.
“Anyway, he was a star with one of those companies. He used narcotics to get through performances and now he is having a bilateral hip replacement. He’s 40. Be careful.”
I gaze out the window at Second Avenue. People leave the bodega across the street carrying ice cream sandwiches, packs of cigarettes, tabloid magazines. There are so many ways to slowly kill the human heart, all in an effort to get through the day.
Dancing is not supposed to be one of them.
Ballet has long been my portal to a happier place. While dancing, I can keep my head in the clouds and my feet firmly connected to the ground. But in 2009, ballet betrayed me. After a few years of warning twinges and soreness, a major ligament in my right hip ripped in two. My labrum was also torn, and there was a mess of fibers embedded deep within the tendons surrounding the joint.
Imagine a serrated knife slicing against the grain of a grapefruit, juice and fibers erupting like a volcano out of its fleshy core. That is what a split jump (grande jete) feels like when a ligament in your hip ruptures. White, searing hot agony and momentary blindness follow. I could hear the piano cranking out a Chopin waltz, dancers were stepping over me, dripping sweat onto my suddenly freezing body, and my vision remained blurry. Was it five minutes or an hour before someone noticed and called for help? In reality it was probably less than 30 seconds before I was lifted to a bench, an ice pack carefully placed beneath my shaking rump.
And so began my odyssey into pain management.
While waiting for surgery, I experienced suicidal ideation on a near-daily basis. I had no quality of life: I couldn’t get that gnawing rat out of my hip. When I moved, the rat metamorphosed into a shard of jagged glass, grinding my flesh into shreds. Sometimes I thought I might be hallucinating, the pain was so bad I thought perhaps I had already left my body and I was simply pain itself, a throbbing, writhing, hopeless embodiment of a condition, not a person at all anymore.
Eventually I had a lengthy arthroscopic surgery, which I was damned lucky to have the insurance to pay for. There was some immediate improvement. My hip stopped clicking when I walked: the tear in my labrum, now repaired, was no longer rubbing into my groin and causing that ghastly sound so loud it made my husband wince when I crossed the room. There was also hope: yes, recovery was a long process -- it took six months to get off crutches alone -- but there was light at the tunnel's end. Eventually I'd balance on my own two legs, I'd turn and jump once more and I would be free from pain.
Yes and no.
It's been six years since my surgery. I’ve subsequently endured a pregnancy on a gutted hip and three and a half years of carrying a child on that hip— yes, the bad one because I can’t seem to balance a kid on my left side. I’ve been under the ministrations of many physical therapists who knead and rub and press my mercurial, angry psoas. The psoas is the Sunset Boulevard of tendons: It is endless and wraps around so many major routes of the body that to suffer pain and weakness there is to live with a body in revolt against walking, breathing and serenity.
I have seen other surgeons, seeking an answer to my lingering pain. They sigh, they shake their heads and say that soft-tissue damage and repair often leaves a person with residual pain. Even a hip replacement, they say, is followed by a less traumatic recovery than soft tissue repair. There is nothing left for a surgeon to do, except to wonder why some people’s pain pathways are more persistent than others and why some parts of the body regenerate and some don’t.
I’ve been back in class for a few years, but the rules have changed. I don’t allow my body to release all the potential energy that once made my jumps explosive. I dance from first position, not fifth, because I can’t torque the hip at such an extreme angle without a shot of pain ripping through my joint like a bullet. Pointe shoes are a thing of the past. I have started to explore theater dance and tap: techniques that are less destructive. I've found new ways to move through movements so that I can still express myself, phrasing my steps just off the beat and leaping a second later. The jump may not be as high, but I can still take an audience by surprise.
What I can't do is stop dancing. Even if I could bear to give it up, I would relinquish my health if I were sedentary. Exercise is one of the most important weapons we have against life’s most common ailments. And every form of exercise exerts pressure on my weakened frame. Here lies the pain management conundrum.
So six years after my injury and surgical odyssey, I am still going to my pain management appointments, discussing prolotherapy and cortisone shots and vitamin D intake and NSAIDS and Pilates and yes, opioid use with my rational, caring doctor. There is no solution; there is only management.
Opioids are under intense governmental and social scrutiny right now, as the media reports on an epidemic of addiction. I read about cases of lost souls, overdoses, suicides, black market pills, portions of towns laid waste by narcotic abuse, and I worry. I worry for the addicts, but I also worry for those of us who would not be able to carry on without responsible pain management.
Tramadol, in small amounts and scattered carefully throughout the month, is a part of my regimen. So too are very hot baths, mineral ice, cortisone injections, ice packs, stress management (um, exercise) and modifying my plans on a daily basis according to my pain level. Sometimes my pain is nonexistent, although my right leg will never feel properly attached to my body again. Other days I feel the tsunami and I simply let go—I accomplish little, I walk slowly, and I roll my stiffened muscles over a tennis ball to break up the knot of agony. I seek help and try to hold on to my rationality. If my husband can get home from work to help me with our toddler, there are times I simply focus on breathing. I’m lucky to have his support. When I don’t have it, I carry our child too far, I stand on my legs too long and I buckle at day’s end, sleeping all night on a searing heating pad.
I never take more than one Tramadol in a 24-hour period. Why? Because I learned very quickly that the second dose never works as well as the first. Instead, the pain lingers, and on top of it I get heartburn, a strong headache and a gnawing agitation. Also, the longer I can go without opioid use, the more I can count on it working when I desperately need it. I have much motivation to avoid using the pills. This makes me lucky: The side effects stand guard against addiction. Still, if I didn’t have a small bottle of painkillers in my drawer, I could never risk exercising or even walking down the street for more than a few blocks. I would live a life of inhibition and confinement, instead of the life I live now: one filled with movement, dancing and meaningful work, with love, child-rearing and long walks in the park.
As society wrings its hands over allegations of doctors handing out pain pills like candy, or over the rise of pharmaceutical companies and their “evil empire,” my feelings are—to say the least—conflicted. I understand why I must submit to the urine screen and to the signed agreement that gives my doctor and my pharmacy the right to share all my records and communicate with other computers in a vast network monitoring controlled substances.
It’s humiliating and it feels personal, but I know it isn’t.
I don’t know exactly where I stand on our country’s addiction problem. How much should the government be involved in monitoring the intake of controlled substances? How does society sort out the responsible drug takers—who depend on small doses of opioids to live functional lives—from those who are abusing drugs? I suppose by monitoring people like me: by counting my pills and watching my pharmaceutical records.
Each time I take my painkiller prescription to a pharmacy, I can’t help feeling suspected of a crime. The pharmacist carefully circles the date on the bottle and the number of pills the doctor has prescribed. There is conferring and then one of the pharmacists tells me what time I can pick up my medication. I leave this miserable moment with relief, feeling cleared of a crime that I know I have not committed.
“Be careful,” my pain management doctor says. “Don’t dance on Tramadol, you won’t know what damage you might be doing. Remember the New York City Ballet dancer. Double hip replacement. Age 40."
He prints out my prescription and hands it to me.
I tell him I’m always careful. “I balance the pros and cons of every pill I take and further balance all my other pain-management tricks against those pills so I can take as few of them as possible.”
“I know that,” my doctor says. “Now let’s talk about Vitamin D.”
I’m grateful for his trust. I’m grateful for a doctor who knows my pain is not manageable without the intervention—at select times—of opioid use. No one else can feel what someone else is perceiving, and that most certainly includes pain. My doctor has evaluated me and concluded after a year of watching me and listening carefully that we can manage the pain—together, imperfectly, and with the help of a highly controversial substance.